Traditional MedicarePrior AuthMedium impact
Spinraza® (nusinersen) (Revised)
Humana·SC · Neurology, Pediatrics·Medicaid
Effective date
Jan 1, 2024
We identified it
Jun 24, 2026
Summary
Humana has revised its prior authorization policy for Spinraza (nusinersen) for treating Spinal Muscular Atrophy, effective January 1, 2024. The policy establishes 8 specific criteria for initial approval and 2 renewal criteria, requiring specialist management and prohibiting combination with other SMN2 directed therapies.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for all Spinraza (nusinersen) claims for Medicare and Medicaid South Carolina members. Providers must document all 8 initial criteria including genetic testing, baseline functional assessments, and specialist consultation. For renewals, document response to therapy with functional assessments and confirm no permanent ventilation. Claims without proper prior authorization will be denied.